Jemds.com Original Research Article ANALYSIS OF 34 CASES OF ENDONASAL ENDOSCOPIC DACRYOCYSTORHINOSTOMY- SURGICAL SUCCESS AND PATIENT SATISFACTION, A CASE SERIES, OUR EXPERIENCE N. Gopinathan Pillai1, Binu Babu2, Anjana Mary Reynolds3, Subadhra S4 1Associate Professor, Department of Otorhinolaryngology, PIMSRC, Thiruvalla. 2Assistant Professor, Department of Otorhinolaryngology, PIMSRC, Thiruvalla. 3Assistant Professor, Department of Otorhinolaryngology, PIMSRC, Thiruvalla. 4Junior Resident, Department of Otorhinolaryngology, PIMSRC, Thiruvalla. ABSTRACT BACKGROUND The conventional treatment of dacryocystitis is external dacryocystorhinostomy. Its success rate varies from 80 - 98%.1-4 But patient’s satisfaction was poor due to facial scar, disruption of medial canthus anatomy and dysfunction of lacrimal pump mechanism. Endoscopic DCR has neither facial scar nor any postoperative distortion of lacrimal pump mechanism and medial canthal anatomy. The objective of this study is to assess the surgical success rate and patient’s satisfaction after endonasal endoscopic Dacryocystorhinostomy (DCR). Study Design- This study was done at Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, between January 2012 and August 2016. There were 34 patients included in this study. Females are more commonly affected than males. Unilateral cases are more than bilateral cases. Their age ranges from 13 - 83 years. Mean age is 35 years. MATERIALS AND METHODS Patients presented with epiphora or swelling below the medial canthus of eye with or without pain, mucopurulent regurgitation from the lacrimal sac into the eye on pressing the swelling. Five patients had concomitant deviated nasal septum, for which septoplasty was done along with DCR. The patency of nasolacrimal duct was assessed by syringing and diagnostic nasal endoscopy. RESULTS The success rate is comparable to other studies of endonasal DCR. The present study has a success rate of 97%. Advantages of endonasal DCR are: (1) There is no facial scar; (2) Preservation of lacrimal pump mechanism; and (3) Retention of medial canthal anatomy. CONCLUSION Endonasal endoscopic DCR overcomes all the drawbacks of external DCR and it is rapidly gaining recognition as a primary modality of treatment for dacryocystitis. Its success rate and patient’s compliance rate are cent percent. KEYWORDS Dacryocystitis, Endonasal Dacryocystorhinostomy, Epiphora, Facial Scar, Nasolacrimal Duct Obstruction. HOW TO CITE THIS ARTICLE: Pillai NG, Babu B, Reynolds AM, et al. Analysis of 34 cases of endonasal endoscopic dacryocystorhinostomy- surgical success and patient satisfaction, a case series, our experience. J. Evolution Med. Dent. Sci. 2017;6(62):4522-4525, DOI: 10.14260/Jemds/2017/978 BACKGROUND into lacrimal sac. From there fluid transmits into the inferior Lacrimal Apparatus meatus of the nose through the nasolacrimal duct. It consists of lacrimal gland, lacrimal canaliculi, lacrimal sac Nasolacrimal duct opening lies about 1.5 cm posterior to the and nasolacrimal duct. Lacrimal fluid is produced by the anterior end of inferior turbinate. This opening is guarded by lacrimal gland. The secretions drain through numerous ducts Hausner’s valve. Lacrimal gland is situated in the into superolateral conjunctival sac of the eye, from there it superolateral part of orbit and upper eyelid. About 12 slender flows to the medial angle of the eye by the contraction of ducts opens in the superior fornix of eye. Lacrimal canaliculi orbicularis oculi muscle. From the medial angle of eye, are 2 slender tubes of about 1 cm length, begins at the lacrimal fluid enters the superior and inferior canaliculi lacrimal punctum situated on the summit of lacrimal papilla. through lacrimal punctum situated on the lacrimal papilla, It runs medially and opens into the lacrimal sac, posterior to which unite to form common canaliculus and drains medial palpebral ligament. Lacrimal sac is lodged in the lacrimal groove and it is 1 cm long and 0.5 cm wide. Its upper Financial or Other, Competing Interest: None. end is blunt, and lower end continuous as nasolacrimal duct. Submission 03-05-2017, Peer Review 01-06-2017, Acceptance 07-06-2017, Published 03-08-2017. Duct is 1.5 cm long and 0.5 cm wide; it passes downwards Corresponding Author: through the nasolacrimal canal to end in the inferior meatus Dr. N. Gopinathan Pillai, of nose. Hausner’s valve, it is a mucosal fold on the medial Associate Professor, side of the nasolacrimal duct opening and acts as a flap valve, Department of Otorhinolaryngology, Pushpagiri Institute of Medical Sciences and prevents air and secretions being blown up. Research Centre, Thiruvalla. E-mail: [email protected] Aetiology of Nasolacrimal Duct Obstruction DOI: 10.14260/jemds/2017/978 The nasolacrimal duct obstruction is the commonest cause of epiphora. J. Evolution Med. Dent. Sci./eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 6/ Issue 62/ Aug. 03, 2017 Page 4522 Jemds.com Original Research Article The causes of Nasolacrimal Duct Obstructions are many revision cases, endonasal endoscopic DCR is the choice of They are- management. 1. Chronic dacryocystitis: It is the commonest cause of epiphora. Chronic dacryocystitis leads to obstruction of External DCR the duct by contracture or stricture. Acute exacerbation of It involves a 12-mm long skin incision on the side of the nose chronic dacryocystitis is also common. Tuberculous to gain access to lacrimal sac. After detaching medial canthal infection of the nasolacrimal sac must be excluded. ligament, the periosteum over the lacrimal crest is divided to Chronic infection may also lead to formation of enter lacrimal fossa. An osteotomy is done in the ascending dacryoliths and subsequent obstructive signs and process of maxilla and lacrimal bone and exposes nasal symptoms. mucosa. The nasal mucosa is incised vertically to create the 2. Congenital defects like nasolacrimal duct atresia and flaps, followed by the lacrimal sac. The lacrimal sac flaps are fistula are also common. The line of fusion between sutured to posterior nasal mucosa to create a direct passage between sac and nose. A silicone tube passed through the sac lateral nasal wall and maxillary process followed by its and kept into the nose to keep the passage open. The anterior canalisation may be incomplete or fistulous tract may lacrimal sac flap is sutured to anterior nasal mucosal flap. develop. Tube is removed after 6 - 8 weeks postoperatively, 3. Trauma: Fracture of the ascending process of maxilla or endonasally. lacrimal bone following road traffic accident or surgery Eighty percent of the lacrimal pathways are inside the may sever or compress the nasolacrimal duct, or sac may nose. So DCR may be performed via an endonasal approach. lead to stenosis or atresia. Therefore, endoscopic DCR is a promising approach to the 4. Benign tumours like nasal polyp may cause absorption of obstruction or stenosis of the lacrimal sac (Saccal ethmoidal bone and obstruction of sac by pressure. obstruction) or nasolacrimal duct (Post-saccal obstruction). 5. Neoplasms of maxillary sinus, ethmoidal sinus may press Congenital dacryocystoceles, unresolved congenital or invade the sac or duct. Lacrimal sac neoplasms are not nasolacrimal duct obstructions are indications for endonasal uncommon. Rodent ulcer of inner canthal region and surgery. Presaccal stenosis are not suitable for an endoscopic subsequent scarring after irradiation may cause procedure. Acquired obstruction of the lacrimal pathways is a obstruction of nasolacrimal sac or duct. common problem of elderly female patients, which can be 6. Granulomatous conditions such as sarcoidosis, Wegener’s corrected by endonasal endoscopic DCR. The best method to granulomatosis5 may also compress the sac or duct. assess the site of obstruction consists of probing the lacrimal pathway and syringing. Fluorescein dye test (Jones I and II) Clinical Features or dacryocystography are no longer performed routinely. CT Epiphora is the cardinal symptom of obstruction. Pressure scan may be used to assess the dacryocystoceles, but it is not over the sac produces a flow of fluid or mucopurulent fluid or routinely employed. Lacrimal duct cyst (Dacryocystoceles) pus from the puncta when infection is present. The sac may may present as a unilateral or bilateral bluish paranasal be palpable if distended by retained fluid or pus. It is tender masses with an intranasal component and nasal obstruction during an acute exacerbation of infection. Then it may symptoms. Lacrimal sac neoplasms are usually non-tender, present as mass near the medial canthus. Benign tumours are but usually present as epiphora. Dacryoadenitis is the most frequently squamous papillomas. Lacrimal sac tumours inflammation of lacrimal gland, and present as painful may be malignant in 50% of cases. The majority of these swelling near the upper eyelid laterally. Dacryocystitis cases are squamous cell carcinoma. present as a swelling near the medial canthus of eye and pressure over the lacrimal sac express purulent secretions Management of Chronic Dacryocystitis from lacrimal punctum. In the middle ages, treatment for chronic dacryocystitis was Diagnostic procedures commonly done are syringing of drainage of abscess externally and extirpation of the lacrimal the passage to test the patency of nasolacrimal apparatus, sac. In late 18th century modern techniques of draining the diagnostic nasal endoscopy and radiography. CT scan is done tear sac into the nose were introduced, whether it is by the to exclude causative